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Inside Dentistry
January 2011, Volume 7, Issue 1
Published by AEGIS Communications
Enhancing Ceramist/Dentist Communication
Jonathan Ferencz, DDS; Pasquale Fanetti, RDT
Using lithium-disilicate ingots to repair worn and discolored anterior dentition.
Increases in the clinical use of all-ceramic restorations and advancements in material sciences have
enhanced the physical properties of modern ceramics, allowing dental ceramists and their dentist clients to
use metal-free restorative options in new ways.
1
Concurrently, new techniques such as chairside and
laboratory CAD/CAM fabrication and porcelain layering and pressing have made the process of creating
highly esthetic and functional restorations faster and easier than before.
2
Though the underlying concepts of ceramic restorations have remained the same since their inception, new
materials enable the creation of restorations with enhanced strength and esthetics, requiring less damage
and preparation to the underlying and surrounding dentition.
2
By using minimally invasive techniques,
dentists can offer patients treatments with little to no discomfort during and after procedures, and correct
issues that typically have been difficult to address.
1
However, working closely with the laboratory is of
paramount importance to the success of any case, because esthetic considerations, preparation design, and
clinical parameters dictate material selection.
Lithium Disilicate
Of the metal-free materials available, glass-ceramic lithium disilicate contains approximately 70% needle-
like crystals by volume in a glassy matrix.
3,4
As a direct result of the controlled size, shape, and density of
the crystalline structure, lithium disilicate demonstrates greater strength and durability than most all-ceramic
systems.
3,4
The material's low refractive index produces unmatched optical properties, such as
translucency, and esthetics that satisfy patients and practitioners.
5
Currently available for two processing techniques, lithium disilicate can be conventionally pressed or milled
using CAD/CAM technologies.
4
Pressable lithium-disilicate restorations (IPS e.max Press, Ivoclar
Vivadent, http://www.ivoclarvivadent.us) are fabricated using a hot-wax press technique, and milled
CAD/CAM restorations (IPS e.max CAD) are fabricated with either laboratory or chairside CAD/CAM
technology.
4,6
Because of the crystal size and length, the flexural strength of pressable lithium disilicate (400 MPa) is
higher than CAD/CAM milled lithium disilicate (360 MPa).
4
However, all other characteristics of the
material are similar, and the choice of two different processing techniques enables dental professionals to
address various issues in the oral cavity that might otherwise limit the indications for metal-free
restorations.
4
The greater strength and presence of a glassy matrix also allows dentists to either
conventionally cement or adhesively bond restorations composed of lithium disilicate.
7,8
Lithium-Disilicate Crowns
When crowns are required, lithium disilicate offers advantages compared to conventional full-crown
materials. Because the preparation for this material is minimal, the risk of pulpal damage is reduced.
9
Also,
veneers and crowns created from lithium disilicate decrease a patient's chances for developing
postoperative periodontal issues, because the margins are thin and typically end at, or just above, the free
gingival margin.
9
Anterior guidance and occlusion also can be maintained when fabricating restorations from
lithium disilicate.
9
Case Planning
When using lithium disilicate for fabricating anterior restorations, as with any restorative case, it is necessary
to first discuss treatment options with the patient, and the laboratory ceramist also should be involved in this
process.
10
Once a specific option is considered, diagnostic tools should be used in order to completely
understand the patient's expectations and any limitations of the proposed restorative therapy. It is the
combined responsibility of dentists and ceramists today to use the plethora of diagnostic tools available to
develop the restoration visually, before subjecting patients to what is, in most cases, irreversible
treatment.
10
Diagnostic Tools
Among the tools used by laboratory technicians and dentists in the diagnosis and treatment planning
processes are preoperative photographs
11
and radiographs, mounted diagnostic cases,
12-15
the provisional
restorations that replicate the proposed final restorations,
16
and, on occasion, white-wax "mock-ups" of the
final case that can be tried in. Preoperative photographs illustrate the condition of the patient's teeth before
a procedure and, when manipulated with imaging software, show how they might look after restorative
treatment.
17
Proper coloring, shading, size, and contouring can be determined in part by examining and
manipulating images of the patient's smile and discussing the proposed changes with the patient,
17
ensuring
that the final treatment will meet everyone's expectations.
Mounted diagnostic casts based on preoperative impressions enable ceramists and dentists to identify
occlusal and/or functional problems that may impact restorative and material decisions. Then diagnostic
wax-ups can be developed to facilitate patient assessment of the proposed treatment, as well as allow
technicians and dentists to predict potential problems that could arise during treatment.
13,14
By using wax-
ups, proper contours for the final restorations can be easily developed and replicated, as wax-ups provide
a detailed and accurate guide during the restorative process and form the basis for other intraoral tools,
such as the silicone matrix.
13-15
Although typically created after assessing the patient's preoperative condition, studying the diagnostic
models, and completing and evaluating the wax-up, provisional restorations still serve a diagnostic function.
In particular, and most importantly, provisional restorations afford ceramists and dentists the opportunity to
gain direct feedback from the patient about the fit, function, and esthetics of the proposed restorations.
16
This information is extremely useful because, ideally, the only difference between provisional and definitive
restorations is the material used.
16
Case Presentation
A 35-year-old man presented with a chief complaint about the appearance of his smile. He had worn
bonded orthodontic brackets for an extended time as a teenager, and he disliked his discolored anterior
teeth, which had been that way for as long as he could remember. As a result, he had been extremely self-
conscious about his appearance.
A comprehensive examination and esthetics consultation was performed, during which the laboratory
ceramist, who worked in-house, participated in the discussion. The examination revealed severe
discoloration and erosion of teeth Nos. 7 through 10 (Figure 1, to which a diet consisting of large amounts
of citrus juice each day may have been a contributing factor. The patient also exhibited a high smile line
(Figure 2, as well as some wear on the lingual aspect of the four incisors.
Collaborative Treatment Planning
Although porcelain-laminate veneers were discussed, the lingual wear on the maxillary incisors directed
treatment toward four crown restorations for teeth Nos. 7 through 10. However, to be as conservative and
esthetic as possible, a lithium-disilicate material (IPS e.max) was chosen.
Then, to treatment plan the proposed restorations, preoperative photographs and radiographs were
uploaded onto a hand-held, touch-screen viewing device (iPad, Apple Inc, http://www.apple.com) and
used to virtually design the proposed esthetic changes. The ceramist and dentist drew the desired length
and esthetic outcome of the final case (Figure 3.
Once this information was discussed and the goals of treatment agreed upon, a diagnostic wax-up was
created. This wax-up incorporated the desired length and form of the planned IPS e.max crowns (Figure 4.
Clinical Preparation
After the patient approved the proposed treatment and esthetic enhancement, provisional restorations were
fabricated in the in-house laboratory according to the diagnostic wax-up using a powder/liquid-based resin
(Telio Lab, Ivoclar Vivadent) (Figure 5.
The teeth were prepared using a silicone matrix (GCLT Laboratory Putty, GC America,
http://www.gcamerica.com) taken from the diagnostic wax-up (Figure 6. After cutting the silicone
impression through the incisal edges, it was placed over the prepared teeth to verify that adequate tooth
reduction was achieved. This would ensure fabrication of the final crowns to the exact dimension of the
diagnostic wax-ups.
A minimally invasive margin placement was completed, because it was not necessary to place the cervical
margins very far below the gingival margin (Figure 7. Such margin placement would be far more likely to
provide long-term soft-tissue health than aggressive subgingival preparation. Because the crowns would be
fabricated from highly esthetic lithium disilicate (IPS e.max) and the low-translucency (LT) IPS e.max ingot
was selected, the discoloration of the labial aspect of the preparation would not be an issue; the labial
thickness of the final crowns would block out any preparation discoloration. Final impressions were taken,
and the patient received the provisional restorations.
In the laboratory, the final impressions were poured, and a white wax mock-up was created based on the
length and form determined by the diagnostic wax-up (Figure 8. At the patient's next appointment, this
mock-up was tried in the patient's mouth to provide an opportunity to preview the length, contour, surface
texture, and form of the final crowns. The patient was encouraged to give his opinion of the esthetics,
because changes are easier to make in wax than in the final ceramic. After the patient, dentist, and ceramist
approved the white wax mock-up, a shade was selected and the provisional restorations were re-
cemented.
Laboratory Procedure
The crowns were waxed on the master cast (Figure 9. Taking a silicone impression of the white wax
mock-up and injecting molten pressable-ceramic wax (Pressable Ceramic Wax, Hi-Tech Wax, Inc,
http://www.hi-techwax.com) simplified this process. This transferred the exact form defined by the white
wax mock-up to the wax patterns to be pressed. The margins were sealed with a specially designed margin
wax (Black Margin Wax, Hi-Tech Wax, Inc).
The wax patterns were cut back to allow layering of the translucent enamels and create a lifelike
translucency at the incisal edge and labial surface (Figure 10. A putty impression of the white wax mock-up
was used to ensure adequate reduction of the incisal and labial surfaces of the wax patterns.
The completed wax-ups were sprued, invested, burned-out, and pressed using the IPS e.max LT ingot in
shade A2 (Figure 11. The pressed crowns were divested and placed in Invex liquid (21% hydrofluoric
acid) (Ivoclar Vivadent) to eliminate the surface reaction layer. The crowns were cut from the sprues and
were ready for layering with the IPS e.max ceramic veneering powders (Figure 12.
A thin wash of Dentin A2 was placed at the cervical area of the crowns to ensure an even color tone during
staining and glazing (Figure 13. Then, a thin layer of Opal Enamel 1 was placed on the labial surface to
create a natural opal-blue effect. The Transpa Neutral and Transpa Incisal shades of veneering powders
were then placed in thin layers over the labial surface, from mesial to distal, to impart the necessary
translucency. Once this first layer was completed, the crowns were fired at a temperature of 750C.
After the first bake, the crowns were placed on the master cast with the lingual index to verify length
(Figure 14. This also allowed the ceramist to verify that the effects placed on the incisal edge were
acceptable prior to applying Transpa Incisal 3 and completing the second bake at 750C.
The crowns were fit back on the master cast after the second firing, and the desired surface texture was
created in the wet ceramic before final firing (Figure 15. Diamond burs and rubber wheels were used to
complete the final crown contours (Figure 16.
The crowns were glazed at 725C and hand-polished with a diamond paste to create a lifelike luster
(Figure 17.
Final Seating
After the provisional restorations were removed and the preparations properly cleaned, the final
restorations were tried in to verify fit, occlusion, and esthetics (Figure 18. The lithium-disilicate crowns
were placed using a dual-curing universal resin cement (Multilink, Ivoclar Vivadent). The patient returned
to the office for final verification of the occlusion and an additional check on the removal of excess cement
(Figure 19. With the esthetics and chip-resistance of the IPS e.max lithium-disilicate crowns, the patient
was very pleased with his treatment outcome.
Conclusion
With enhanced strength and optical properties, materials like IPS e.max lithium disilicate enable ceramists
and dentists to satisfy patient requests for highly esthetic restorations while simultaneously fulfilling clinical
and functional requirements.
2
Additionally, the material's capacity for conventional cementation and
minimally invasive preparation designs provide patients with conservative options, even when full-coverage
crowns are necessary.
However, regardless of the material used to fabricate esthetic crowns, restorative and esthetic success is
predicated on thorough communication and collaboration among the dentist, ceramist, and patient.
Incorporating proven diagnostic and treatment planning tools into the communication process enhances the
predictability treatment outcomes.
Disclosure
Dr. Ferencz has received honoraria for lectures/speaking engagements from Ivoclar Vivadent.
References
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crowns: a two-year report. J Am Dent Assoc. 2010;141(Suppl 2):10s-4s.
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Dentistry. 2009;5(10):58-66.
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8. Fabianelli A, Goracci C, Bertelli E, et al. A clinical trial of Empress II porcelain inlays luted to vital teeth
with a dual-curing adhesive system and a self-curing resin cement. J Adhes Dent. 2006;8(6):427-431.
9. Terry DA, Leinfelder KF, Geller W, eds. Aesthetic and Restorative Dentistry: Material Selection
and Technique. 1st ed. Stillwater, MN: Everest Publishing Media; 2009:152-153.
10. Donovan TE, Cho GC. Diagnostic provisional restorations in restorative dentistry: the blueprint for
success. J Can Dent Assoc. 1999;65(5):272-275.
11. Ahmad I. Digital dental photography. Part 2: Purposes and uses. Br Dent J. 2009;206(9):459-464.
12. Garcia LT, Bohnenkamp DM. The use of diagnostic wax-ups in treatment planning. Compend Contin
Educ Dent. 2003;24(3):210-212, 214.
13. Denehy GE. A direct approach to restore anterior teeth. Am J Dent. 2000;13(Spec No):55D-59D.
Figure 1 Figure 2 Figure 3
14. Vanini L, Mangani F, Klimovskaia O, eds. Conservative Restoration of Anterior Teeth. Viterbo,
Italy: ACME. English edition; 2005.
15. Behle C. Placement of direct composite veneers utilizing a silicone buildup guide and intraoral mock-
up. Pract Periodontics Aesthet Dent. 2000;12(3):259-266.
16. Reshad M, Cascione D, Kim T. Anterior provisional restorations used to determine form, function, and
esthetics for complex restorative situations, using all-ceramic restorative systems. J Esthet Restor Dent.
2010;22(1):7-16.
17. Helvey GA. How to increase patient acceptance for cosmetic dentistry: Cosmetic imaging with Adobe
Photoshop Elements 4.0. Dent Today. 2007;26(2):148-153.
Jonathan Ferencz, DDS
Clinical Professor of Prosthodontics
University College of Dentistry
New York, New York
Pasquale Fanetti, RDT
Dental Laboratory Technician
NYC Prosthodontics
New York, New York
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